Comparing nursing terms from patient records to the ICNP, beta version.

Information about patient care is documented in order to promote continuous care and outcomes evaluation. With the computer advent in the healthcare area, standards documentation became mandatory. Many vocabularies are being developed, however, they are still insufficient to support clinical documentation. This study investigated the words used to document inpatients clinical assessment. These words were mapped into the International Classification for Nursing Practice (ICNP). The mapping process showed that only 247 words from 761 selected were included into the classification. Consequently, improvements have to done to facilitate the use of standard terminologies in the practice to improve the documentation itself.